MORNING REPORT

Date : Monday, May 3th, 2021

Physician in charge
I : dr. Reza, dr. Verina, dr. Vidi
II Consultation : dr. Sandi
II HCU : dr. Sandi
II Incovit : dr. Firman
II ER : dr. Gunawan, dr. Angel
II ER incovit : dr. Reta
Chief on duty : dr. Fitri
Consultant on duty : dr. Laksmi Sasiarini, SpPD-KEMD
 Summary of Database
Mr. A/66 yo/ Bougenville Incovit
Chief Complaint: Shortness of Breath
History of Present Illness:
- Shortness of breath since 2 weeks ago worsened since 1 day ago. The complaint folowed
by acute productive cough with withish sputum since 1 weeks ago.
- He also complaint Nausea and vomiting in the last 1 weeks, vomited about 50-100 cc, 3-4
times per day consisting food residue and water.
- Urinary catheter had been inserted at 5/4/2021 until 25/4/2021, the urinary catheter had
released because he felt dysuria. The complaint didn’t followed by fever.
- He had diagnosed Confirmed case covid 19 and hospitalization at 5/4/2021, patient
refered to RSSA because worsening of condition
 Summary of Database
Past Medical History:
No significant past medical history

Family History:
Patient is unaware of her parents and elders medical history

Social History:
There was no history contact with patient confirmed case COVID-19. there was no history of
Vacination of COVID-19. He is a trader. He lives in Tidar Malang

Review of System:
General: General weakness
Respiratory: Shortness of breath
Gastrointestinal: Nausea Vomiting
 Physical Examination
General appearance looked moderately ill Sat O2 98% on NRBM 10lpm
GCS 456 Vas Score 3/10
BMI : 20,7 Kg/m2

BP 139/82 mmHg HR 85 bpm RR 22 tpm Tax 36.2 oC

Head Physical examination wasn’t performed

Neck Physical examination wasn’t performed

Chest Physical examination wasn’t performed

Lung Physical examination wasn’t performed

Cardio Physical examination wasn’t performed

Abdomen Physical examination wasn’t performed

Extremities Odem (-), warm acral (+).

 Laboratory Findings (2/5/2021)
LAB VALUE NORMAL LAB VALUE NORMAL

Leukocyte 18.620 4.700 – 11.300 /µL Ureum 162,6 20-40 mg/dL

Hemoglobin 15,5 11,4 - 15,1 g/dl Creatinin 2,54 <1,2 mg/dL

e
HCT 46,8 38 - 42%

Thrombocyte 245.000 142.000 – 424.000 /µL Sodium 131 136-145 mmol/L

MCV 83 80-93 fl Potassiu 4,77 3,5-5,0 mmol/L

m
MCH 28 27-31 pg Chloride 95 98-106 mmol/L

Eo/Bas/Neu/ 0,1/0,1/94,2/2, 0-4/0-1/51-67/ PPT 11,9 9.3-11.4 second

Limf/Mon 1/3,5 25-33/2-5
APTT 24,1 24.8-34.4
INR 1,16 0.8-1.30

CRP 1,18 < 0,3 SGOT 37 0-40 U/L

Procalcitonin 0,48 < 0,5 SGPT 40 0-41 U/L

Fibrinog 398
en
ALC 400 D-dimer 4,03

NLR 43,85
 Urinalysis (29/04/2021)
LAB VALUE NORMAL LAB VALUE NORMAL
Turbidity Cloudy 10 x
Color Yellow Epithelia 3,3 ≤1
pH 6,0 4.5 – 8.0 Cylinder Negative
SG 1025 1.005 – 1.030 Hyaline
Glucose Negative Negative Granular
Protein 2+ Negative Other
Keton Negative Negative
Bilirubin Negative negative 40 x
Urobilinogen 3,2 negative Erythrocyte 26,6 ≤3
Nitrite Positive negative Leukocyte 9.287 ≤5
Leukocyte 3+ negative Crystal -
Erythrocyte 2+ negative Bacteria 6211,0 ≤23 x 103/ml
Other
 Blood Gas Analysis (2/5/2021)

With NRBM 10lpm Normal

pH 7,4 7.35-7.45
pCO2 30,2 35 – 45 mmHg
pO2 120,8 80 – 100 mmHg
HCO3 18,9 21 – 28 m mol/L
O2 saturation 98,4 > 95 %
BE -6,1 (-3) - (+3) m mol/L
Temperature 37
Hb 15,1
Conclusion: Ascidosis metabolic fully compensiated with
alkalosis respiratoric with PF Ratio 201 (Mild ARDS)
Chest X-Ray (2/5/2021)
 Chest X-Ray (2/5/2021)
• AP position, symmetric, enough KV
• Soft tissue and bone are normal
• Trachea is in the middle
• Hemidiaphragm D is tenting and S is dome-shaped
• Phrenico-costalis angle D and S are sharps
• Pulmo: bronchovascular pattern is normal, Hilus D/S normal,
Basal Peripheral infiltrate bilateral.
• Cor: site is normal, size CTR 67%, cardiac waist (+)
• Aorta: Elongation

Conclusion: Pneumona typical ec. Virus, Cardiomegaly

 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

1. Confirmed case (-) (-) Non- Pharmacology: Pmo:

Mr. A/66 yo/ Bougenville Incovit Pneumonia O2 NRBM 10lpm Shortness of
-
COVID-19 Criticall breath,
Subjective degree Pharmacology: cough, VS,
- SOB (+), cough (+) - IV Vitamin C 1x200 mg BGA, RT PCR
- Nausea Vomiting (+) - Drip NAC 5 gram/72 hours evaluation
- IV Dexamethasone 1x6mg swab H-30
Objective - PO Zinc 3x20 mg
RR 22 tpm; Temp 36.2 C - PO Vitamin D3 1x5000 unit Pedu:
SpO2 98% NRBM 10lpm - SC Heparin 3x7500unit - Explain
- PO Avigan 2x600mg (H3) about the
Laboratory dangers of
WBC :18.620 covid-19
Diff Count 0,1/0,1/94,2/2,1/3,5 - Explain
ALC 400 about general
NLR 43,85 awareness of
BGA : physical
pH/pCO2/pO2/HCO3/BE/SatO2 distancing
7,4/30,1/120,8/18,9/-6,1/98,4%
PF Ratio : Mild ARDS
Swab RT PCR Sars COV 2
29/4/2021 (Positive)

CXR 2/5/21 :
Pneumona typical ec. Viral
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

2. Lower - Urine Non- Pharmacology: Pmo:

Mr. A/66 yo/ Bougenville
Complicated Culture + - Urogenital Hygine VAS, UL
Incovit UTI dt CAUTI Drug
Sensitivit Pharmacology: Pedu:
y - Oral Intake 1-2L/day - Explain
Subjective
- IV Ciprofloxacin 2x200mg about the
- Urine catheter Inserted Urogenital
about 2 weeks Hygine to
- Dysuria (+) prevent
worsened
Objective UTI
VAS 3/10

Laboratory
WBC : 18.620
Diff Count
0,1/0,1/94,2/2,1/3,5

UL :
Nitrit +
Leukosit +3
Lekosit 9282,7 LPB
Bakteri 6211,0 x 10³/mL
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
3. Nausea 3.1 GI (-) Non Pharmacology S, VS
Mr. A/66 yo/ Bougenville
Vomiting manifestation - Soft Diet 1800kcal/day
Incovit of Covid 19 Pedu :
3.2 Uremic Pharmacology Educate the
Subjective Gastropathy - IV Omeprazole 1x40mg patient about
- Nausea and vomiting - IV Metoclopramide the relation of
since 1 weeks ago 3x10mg if needed this symptom
- Vomiting 50-100cc, 3- to the main
4x/day, contained fluid suspected
and food residu problem whom
the patient may
Objective have.
(-)

Laboratory
Ur/Cr 162,2/2,54
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
4. AKI stage 2 4.1 Volume (-) Non Pharmacology PMo :
Mrs. Z/66 yo/Dahlia Incovit
(Pre Renal depletion - Equal Fluid balance VAS, UOP,
Type) 4.2 Related to Ur/Cr, Fluid
Subjective CAUTI Pharmacology balance, renal
- Nausea and vomiting - IVFD NaCl 0,9% emergency
since 1 weeks ago 1500cc/24hour
- Urine catheter Inserted Pedu :
about 2 weeks Educate the
- Dysuria (+) patient about
the cause of
Objective AKI can caused
VAS : 3/10 by Nausea and
Vomiting
Laboratory
Ur/Cr 162,2/2,54
UL :
Nitrit +
Leukosit +3
Lekosit 9282,7 LPB
Bakteri 6211,0 x 10³/mL
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed

5. (-) (-) Non- Pharmacology: Pmo:

Mr. A/66 yo/ Bougenville
Hypercoagulab - O2 NRBM 10lpm FH (APTT),
Incovit le State relate Fibrinogen,
d to COVID-19 Pharmacology: D-dimer,
Infection - SC Heparin 3x7500unit Sign of
Subjective Bleeding
- SOB (+), cough (+)
- Nausea Vomiting (+) Pedu:
Awearness
Objective
sign of
RR 22 tpm; Temp 36.2 C bleeding
SpO2 98% NRBM 10lpm

Laboratory
D-dime r 4,03
Swab RT PCR Sars COV 2
29/4/2021 (Positive)

CXR 2/5/21 :
Pneumona typical ec. Virus,
Cardiomegaly
 Problem Analysis

Confirmed Case Covid-19

Hypercoagulable State Nausea Vomiting

Catheter Volume Depletion

Complicated UTI AKI stage 2

 Risk Factors Analysis
Problem Theory Patient
COVID-19 • Had history of contact or Unknown
travelling
• Contact with confirmed
case
• Red area
• Health worker (high risk)
And Severe illness risk
factor :
• Chronic lung disease or
moderate to severe
asthma
• Cardiac disease
• Immunocompromised
• Severe obesity (body
mass index [BMI] of 40 or
higher)
• Diabetes
• Chronic kidney disease
undergoing dialysis
• Liver disease

CDC
Key Message Diagnosis
Key Message Diagnosis
Key Message Diagnosis
Key Message Treatment
Key Message Treatment
Key Message Treatment
 Condition This Morning

• GCS : 456
• Blood Pressure : 137/81 mmHg
• Heart Rate : 80 bpm
• Respiration Rate : 22 tpm
• Tax : 36,4 C
• SpO2 : 97% NRBM 10lpm
THANK YOU